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MAY-11-2007 10:19 FROM:CHOL/MFT 209 476 3096 TO:2094683433 P.2/4 <br /> # 05/10/2007 THU 15. 12 FAX 20946 3 SJC END 0002/004 <br /> UNIFIED PROGRAM CONSOLIDATED FORM PR 0.PAID13249 <br /> P Rt tbWOfi260 <br /> UNDERGROUND STORAGE TANKS FACILITYits °� <br /> (onc)3ar:e pas'Silo) <br /> (Check <br /> OF AC7'[ON ❑ I VL;W SI'rli PERMIT' ❑3 RM4LINALPERMIT tbf!CDAN.LOFINFORMArMN ❑? PIERMAr�ENTLY Cl.()SED SITE <br /> (Chak ane Womanly) t--t i..J4AMmHomPfRMl1 .lydiigm <br /> _ '•.`t❑S.r,\AK RR1.10Yr•7J <br /> ❑6.T04P0RARY Srrr;C A=RA AM <br /> 1.FACILI'T'Y I SITE IVI<ORm PION 7373 WUr I.N.S'I'Oc,It rON <br /> I)USINIaSSNA .(Saimast=Auun'YNAM€aDRA•Dnoiib;iA.kw;As) 3 I`A I).1TY1Dh I'►tlIW — <br /> KAISER PERMANEKrE 1:A0002602 PRDZ32494 <br /> NtiAltlitil"CROSS Sl'RI_l:I FA IL 11Y OWNIA TYPE <br /> 4M ❑4 I.00ALAGENC'Y/D19TRIC7- <br /> W ES•I' ® l.CORPCIRA7YpV [�S 4'Vt,Nl"Y AG NCV*13USIN1"$ U OAS STATION Q ] 1+RM ❑5 COMMPROA1. C]2 INI3rYlD�uAL <br /> 1'YErI: ^�� ❑ ❑G STATEAtirl`GY• <br /> �]2 D><STPHAI'1OR C 4.PROCESSOR E]6 O'I'liLlt 169 3 PARTNERSIIlP 4 <br /> TOTALF NIIMHHK t)h'i ANIS IS Wilily UW 1pt An Mervation or--' <br /> if owner of UST is a tlublic rgcn.y pame ol8uo;wjs4w ard:vuroat,sect+on w office Which olteial",s <br /> RENIA1NING AT 517"Li irusi farads? lilt(A ll i its is the com ct pawn for the tmk awards.) <br /> Jai U yeS M Na _—...._ Jus S 'TQ 1-4 N &mcf,P� fns <br /> 11. PROPERTY OWNER INFORMATION <br /> PROPERTY OYl'Nhlt wAM1r — — sw NFtONF'. <br /> JU@ <br /> KAISER PEKMANENTE (2U9)476-2000 <br /> MAIL,NO pK-1"BEET ADDRES:i "'-"' " <br /> J79 <br /> 1305 TOMMY DON <br /> CITY Jia STAT J1) 2Ip 65131:.-. 412 <br /> sTacK m _CA 95210 <br /> ► 1.31T'Y OWNER TYPE ® I.CORPOIt V0014 ❑ a INDIVIDUAL. ❑4.1A)CA1,AGENCY r DISTRICT C1 6 SPATE AGENCY <br /> 03 iwaNERS111P C3 5 <olwrY 4GF.NCY U 7.L.m.)L•RALAGE14CY ilii <br /> III.TANK OWNER INFORMATION <br /> .NIC OWNER NAME: �� 41i Pf1 NL J15 <br /> KAISER PERMANCN`i`E 209 476-2000 <br /> MAILTKC-,Ol t (till"T ADDRESS <br /> J6 <br /> 7373 WEST IANE <br /> fl"Y 417 S I KI'hx111 ZIP COOP 419 <br /> STOCK'T'ON __.. ........___-- ,_.CA 95210 <br /> fANKOAVNIiK!'Yi'4 ® 1 C0RPORA7r10N ❑2.ININV1$)AL 4 LOCAI.AGLNCY/DISTRICT ❑ 6 3*1"A'IWAGENCY t"t <br /> 3.PAICTNERSHIP Z3 5 COkIN7"Y,AGENCY ❑ 7.1.7;DI:R.Al,AGENCY <br /> IV.BOARD OF EQUALIZATION TIST STORAGE,FEE ACCOUNT NUMBER <br /> '1 Y(I-K)I IQ 44- 4¢033865 CRIT(916)322-9669 i1 ue'lions t)risc J)t <br /> V.PETROLEUM UST FINANCIAL RESPONSIBILITY <br /> )NUICAI'f.MITI l tO0(s) 19(,SELF-WSURFD M 4 Sligi-1"Y 1}ONI) C3 7.STATE Fl sr) 7 rt) LCCALGOvT ML-CIIANISM <br /> ❑2.(1UARAN'1'1'7-.E: ❑s.D.r.:"rfrR OFCRfrTll-I- U Lt STATE FUND A CFO 1.:''C]'!'sE2 i$I 99.OTIN'dt <br /> ❑3.INSORANCE 6.EXL:h1P1[ON ❑ 9.STA1E FUND&Cu 422 <br /> —_...__._ V1.LEGAL NOTIFICATION AND MAILING ADDRESS <br /> cvvk one box la ind.aate wit ich adtfrosr.shsaikl be used for legd notifications find ittai lnig. a a <br /> IN1.PAClL1'1 Y D 1...1 Rn!L.lt'I'ti"OWNER ❑3 TANK OWNER. 423 <br /> LCgN aatfielttm:ro anti milllmg Will ne sdnt W 1Po lank aWrier unless box 1 or 2.s aheckad. <br /> 11.A PLI ANI'SIGNATURE <br /> Ceiti Ficattun-1 ahidy diva the mfunsiimon.31MWed Iwroin is tnwand ava auto tlwbom ofh.yk+towla J1w. — <br /> SIGN ATURf.;OF A rl ICANT DATE. 121 i'IlOK1; <br /> ;: /1 t!17 -7, <br /> AMIi of,,01,L.ICAN'r(print, 4X TITLE OF APPLI AN"I427 <br /> S PATE IJVI*FA(;1Lf fY N1JMI))iR tya wa+l tical) 428 1999 UPGRADE CL•RTIf1CAIT,NUM1313R(rwj.,il iu.451 129 <br /> Is 199SCanphant?Y <br /> 01IC"1 (1/99 revi%ed) <br />